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Adhya and Laha suggest nicking the skin while Alan S. Graham, M.D. the needle remains in place, which may prove Ken Tegtmeyer, M.D. useful as long as the operator takes care not to Dana Braner, M.D. cause damage by inadvertent movement of the Oregon Health and Science University indwelling needle during the process. They also Portland, OR 97239 grahamal@ohsu.edu refer to an interesting study that describes the use of a small-gauge pilot needle to locate the internal 1. McGee DC, Gould MK. Preventing complications of central jugular vein and an innovative technique to then venous catheterization. N Engl J Med 2003;348:1123-33. 2. Wang R, Snoey ER, Clements RC, Hern HG, Price D. Effect stabilize it.4 This small-gauge pilot needle may be of head rotation on vascular anatomy of the neck: an ultrasound particularly useful when patients have coagulop- study. J Emerg Med 2006;31:283-6. 3. Karakitsos D, Labropoulos N, De Groot E, et al. Real-time athy or when ultrasonography is not available. ultrasound-guided catheterisation of the internal jugular vein: We agree that, ideally, an experienced opera- a prospective comparison with the landmark technique in crititor should be present for all central venous cath- cal care patients. Crit Care 2006;10:R162. eterization procedures. This is especially impor- 4. Tripathi M, Pandey M. Anchoring of the internal jugular vein with a pilot needle to facilitate its puncture with a wide bore tant for patients with known risk factors for needle: a randomised, prospective, clinical study. Anaesthesia 2006;61:15-9. difficult catheterization.

Long-Term Follow-up after Treatment of Rabies by Induction of Coma

To the Editor: In 2005, Willoughby and colleagues1 reported on a 15-year-old girls survival from rabies encephalitis the sixth such case that had been reported in humans after treatment with a novel therapeutic regimen that included ketamine, ribavirin, and amantadine. Five months after exposure, she still had dysarthria, weakness in the left hand and foot, bilateral extensor plantar response, generalized choreoathetosis, intermittent dystonia, and a lurching gait. Here we report on the functional outcomes 18 months and 27 months after her initial exposure to a rabid bat. Her generalized choreoathetosis completely resolved by 2006. A trial of therapy with carbidopa levodopa caused worsening of abnormalities in her gait. A cerebrospinal fluid analysis in September 2005 showed normalization of the protein level and the white-cell count, with decreased levels of biopterin. Eighteen months after her exposure to rabies, her dysarthria and gait abnormalities had significantly improved, but she could not return to her previous level of participation in sports. She resumed classes full time in high school without having difficulties with either learning or memory. On neurologic examination, the patient showed no choreoathetoid movements during four separate visits with three neurologists and two rehabilitation specialists. She had normal affect and cognition, ataxic dysarthria (see video, available with the full text of this letter at www.nejm.org), and normal cranial-nerve functions. Also evident in the video are both mild weakness in the left foot dorsiflexor and mild dystonia in the left hand, without weakness on surface electromyography. She also had slowed alternating movements in the left hand and fingers and paresthesia in the region of the bat bite. Her deep-tendon reflexes were symmetric throughout, and her plantar responses were flexor. She had mild ataxia, especially during running (see video). Analysis of the cerebrospinal fluid showed six unique oligoclonal bands. A mildly elevated level of neopterin and decreased levels of 5-hydroxyindoleacetic acid and homovanillic acid suggested decreased turnover of dopamine and serotonin. Magnetic resonance imaging of the brain showed resolution of the hyperintensities in the basal ganglia that had been seen on T2weighted images in November 2004. Twenty-seven months after exposure, the patient continued to have fluctuating dysarthria and gait difficulties, plus an intermittent sensation of cold in the feet. She had no difficulties with her instrumental activities of daily living, including driving. In high school, she took college-level courses in English, physics, and calculus. She scored above average on a national college achievement test, graduated from high school in 2007,
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and planned to attend a local college in the fall. She had no problems with peer relations or mood disorders. Of five other patients with well-documented survival after rabies encephalitis,2-7 all of whom received conventional care, only one had a satisfactory outcome,2 whereas the others had persistent cerebellar and striatal signs.7,8 The combined treatment with antiexcitatory agents (ketamine, midazolam, and phenobarbital) and antiviral agents (ketamine, amantadine, and ribavirin) used by Willoughby et al. may have contributed to this patients favorable outcome, and such treatment warrants further evaluation. William T. Hu, M.D., Ph.D.
Mayo Clinic College of Medicine Rochester, MN 55905

1. Willoughby RE Jr, Tieves KS, Hoffman GM, et al. Survival

after treatment of rabies with induction of coma. N Engl J Med 2005;352:2508-14. 2. Hattwick MA, Weis TT, Stechschulte CJ, Baer GM, Gregg MB. Recovery from rabies: a case report. Ann Intern Med 1972;76: 931-42. 3. Porras C, Barboza JJ, Fuenzalida E, Adaros HL, Oviedo AM, Furst J. Recovery from rabies in man. Ann Intern Med 1976;85: 44-8. 4. Rabies in a laboratory worker New York. MMWR Morb Mortal Wkly Rep 1977;26:183-4. 5. Follow-up on rabies New York. MMWR Morb Mortal Wkly Rep 1977;26:249-50. 6. Madhusudana SN, Nagaraj D, Uday M, Ratnavalli E, Kumar MV. Partial recovery from rabies in a six-year-old girl. Int J Infect Dis 2002;6:85-6. 7. Alvarez L, Fajardo R, Lopez E, et al. Partial recovery from rabies in a nine-year-old boy. Pediatr Infect Dis J 1994;13:1154-5. 8. Jackson AC, Warrell MJ, Rupprecht CE, et al. Management of rabies in humans. Clin Infect Dis 2003;36:60-3.
Correspondence Copyright 2007 Massachusetts Medical Society.

Rodney E. Willoughby, Jr., M.D.

Medical College of Wisconsin Milwaukee, WI 53226

Howard Dhonau, M.D.

Fond du Lac Regional Clinic Fond du Lac, WI 54935

Kenneth J. Mack, M.D., Ph.D.

Mayo Clinic College of Medicine Rochester, MN 55905

A video showing the patient 18 months after exposure to rabies is available with the full text of this letter at www.nejm.org.

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